Provider Demographics
NPI:1790987600
Name:FISHBACK, DAWN B (RN)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:B
Last Name:FISHBACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1522
Mailing Address - Country:US
Mailing Address - Phone:315-789-9764
Mailing Address - Fax:
Practice Address - Street 1:1605 STRONG RD
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-9352
Practice Address - Country:US
Practice Address - Phone:585-924-0459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY502649-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02691578Medicaid